Shalom Gardens Health & Rehabilitation

In the surveyor’s words

From the most serious findings on record at Shalom Gardens Health & Rehabilitation, in the surveyor’s own words.

• Immediate jeopardy, isolatedF678May 6, 2026

  Based on staff interview, facility document review and clinical record review, the facility staff failed to provide basic life support measures to include initiation of cardiopulmonary resuscitation (CPR) in accordance with the resident's wishes/advance directives for one of twenty-four residents in the survey sample (Resident #1). Resident #1, with physician orders for a full code status requiring CPR in case of cardiac/respiratory arrest, had no immediate assessment, basic life saving measures, or CPR efforts initiated, when the resident was found unresponsive and without pulse/respirations, resulting in the resident being pronounced deceased . […]

• Immediate jeopardy, isolatedF725May 6, 2026

  Based on staff interview, facility document review and clinical record review, the facility staff failed to provide sufficient nursing staff for assessment/monitoring of one of twenty-four residents in the survey sample (Resident #1). With no nurse assigned, Resident #1 had no assessment or administration of medications/treatments on the morning [DATE]. Resident #1 was found unresponsive on [DATE] at 12:30 p.m. without pulse or respirations and was pronounced deceased without initiation of required CPR (cardio-pulmonary resuscitation). This resulted in the identification of immediate jeopardy.The findings include:Staffing schedules documented no nurse assigned to care for Resident #1 on [DATE] during the day shift (7:00 a.m. to 3:00 p.m.). […]

• Actual harm, isolatedF684Nov 5, 2024

  Based on observations, medical records review, and staff interviews, the facility failed to ensure one of five residents (Resident #3) received emergency treatment and care in accordance with professional standards of practice. The findings include: Resident #3 was admitted to the facility on [DATE] with a diagnosis of diabetes, cerebral infractions (stroke), dysphagia (difficulty swallowing), Muscle and Facial Weakness, Transient Cerebral Ischemic Attack, DNR, Contracture of Muscles (Right Upper Arm), and Hemiplegia and Hemiparesis following Cerebral Infarction Affecting the Right Dominant Side. […]

• Actual harm, isolatedF686Dec 16, 2021

  Based on observations, staff interviews, clinical record review, facility documentation review, and in the course of a complaint investigation, the facility staff failed to prevent pressure wounds resulting in harm for one Resident (Resident #1) in a sample size of 3 Residents. For Resident #1, the facility staff failed to provide interventions to prevent the worsening of pressure wounds resulting in an avoidable stage 4 sacral wound and unstageable pressure wounds of bilateral heels. The Resident was hospitalized for infected pressure wounds. This is harm. The findings included: On 12/14/2021 at approximately 11:00 A.M., Registered Nurse B (RN B) and this surveyor observed Resident #1 in her room with the head of the bed elevated approximately 60 degrees. […]

• No harm, potential for more than minimal, patternF657May 6, 2026

  Based on clinical record reviews, observations, staff interviews, and facility documentation the facility staff failed to review and revise the comprehensive person centered care plans for three residents, Resident #15 (R15), Resident # 23 (R23), and Resident #24 (R24) out of a survey sample of 24 residents. The findings included:1. Facility staff failed to implement fall interventions and precautions after R15 had a fall.On 5/5/26, a clinical record review was conducted. During the review, R15's care plan was reviewed. The care plan had a concave mattress as the intervention for R15's fall on 3/9/26 and was the only intervention for that fall.On 5/5/26 at 2:00 pm, an observation was made of R15's bed and he did not have a concave mattress on his bed. […]